A physician shortage, lack of medical regulation and low education levels are making it difficult to implement safe male circumcision programs in Africa in an effort to curb the spread of HIV, the Wall Street Journal reports (Schoofs, Wall Street Journal, 9/7). According to final data from two NIH-funded studies -- conducted in Uganda and Kenya and published in the Feb. 23 issue of the journal Lancet -- routine male circumcision could reduce a man's risk of HIV infection through heterosexual sex by 65%. The results of the Uganda and Kenya studies mirrored similar results of a study conducted in South Africa in 2005. In response to the findings, the World Health Organization and UNAIDS in March recommended the procedure as a way to help reduce transmission of the virus through heterosexual sex (Kaiser Daily HIV/AIDS Report, 8/10).

According to the Journal, less than 20% of men in African countries with high HIV prevalence -- such as Malawi, Rwanda, Zambia and Zimbabwe -- are circumcised. In Kenya, more than 80% of men are circumcised; however, complications from the procedure are common and show the potential risks of implementing widespread circumcision programs throughout the continent, the Journal reports.

A 2004 study among 1,000 African boys and teenagers who received circumcisions found that 35% of those circumcised by ritual circumcisers -- who often have only rudimentary medical training -- experience side effects such as infection, excessive bleeding and painful urination. The study also found that 17% of those circumcised in medical settings, including private clinics, experienced adverse side effects. Less than 2% of those circumcised with modern medical procedures and equipment experienced the side effects, the study found.

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Some health workers in Africa lack adequate equipment to perform safe circumcision, such as scissors sharp enough to not leave ragged edges. Many ritual circumcisers often perform the procedure without sterilization or bandages, and because the penis is rich in blood vessels, excessive bleeding and infection can occur if the vessels are not tied properly. In addition, lignocaine, a local anesthetic commonly used in Kenya, can cause irregular heartbeat and cardiac arrest if injected into the bloodstream rather than into tissue. Many Kenyans with little education do not understand the difference between ritual healers and doctors, the Journal reports.

According to the Journal, some social advocates in Kenya are urging parents to have their sons circumcised in medical rather than ritual settings. In addition, increased education in the country has spread knowledge about sanitary medical procedures. Some Christian churches in the country have begun to offer safe, medical circumcisions in their communities.

Peter Cherutich, a member of the Kenyan Ministry of Health's circumcision task force, said he hopes the government will begin to offer no-cost circumcisions. The government is seeking support from donor governments and international organizations to fund such a program, the Journal reports (Wall Street Journal, 9/7). The President's Emergency Plan for AIDS Relief last month announced it would begin providing money for male circumcision programs in some African countries in an effort to reduce the spread of HIV. PEPFAR focus countries have been invited to request program funding to increase access to the procedure (Kaiser Daily HIV/AIDS Report, 8/20).

According to Cherutich, the health ministry's circumcision task force will consider training nurses to perform the procedure to help address the shortage of physicians available to provide circumcisions. However, he added that it might not help solve the problem because the majority of nurses in Kenya are women, and many traditional cultures object to women performing the procedure. Cherutich said that increased access to safe circumcision could "make a huge difference in the HIV epidemic" (Wall Street Journal, 9/7).

Washington Post Examines Kenyan Luo Tribe's Resistance to Circumcision
In related news, the Washington Post on Friday profiled the Kenyan Luo tribe, the only major Kenyan tribe that does not traditionally circumcise boys. According to the Post, about one in five Luo adults is HIV-positive, compared with one in 17 throughout Kenya. Robert Bailey, an epidemiologist at the University of Illinois-Chicago who oversaw the Kenyan circumcision trial, said that a well-run circumcision program could reduce HIV prevalence among Luo men from 18% to 8% over 20 years. In addition, women would be less likely to contract HIV because fewer men would have the virus (Timberg, Washington Post, 9/7).

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